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Video decision support tool for advance care planning in dementia: randomised controlled trial

BMJ 2009; 338 doi: (Published 28 May 2009) Cite this as: BMJ 2009;338:b2159

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  1. Angelo E Volandes, instructor1,
  2. Michael K Paasche-Orlow, associate professor2,
  3. Michael J Barry, professor1,
  4. Muriel R Gillick, professor3,
  5. Kenneth L Minaker, professor1,
  6. Yuchiao Chang, senior statistician1,
  7. E Francis Cook, professor4,
  8. Elmer D Abbo, assistant professor5,
  9. Areej El-Jawahri, research fellow1,
  10. Susan L Mitchell, associate professor 6
  1. 1General Medicine Unit, Department of Medicine, Massachusetts General Hospital, 50 Staniford Street, Boston, MA 02114, USA
  2. 2Department of Medicine, Boston University School of Medicine, 715 Albany Street, Boston, MA 02118, USA
  3. 3Department of Ambulatory Care and Prevention, Harvard Medical School/Harvard Pilgrim, 133 Brookline Ave, Boston, MA 02215, USA
  4. 4Department of Medicine, Brigham and Women’s Hospital, 1620 Tremont Street, Boston, MA 02115, USA
  5. 5Department of Medicine, University of Chicago, 5801 South Ellis, Chicago, IL 60637, USA
  6. 6Hebrew SeniorLife, 1200 Centre Street, Boston, MA 02131, USA
  1. Correspondence to: A E Volandes avolandes{at}
  • Accepted 3 February 2009


Objective To evaluate the effect of a video decision support tool on the preferences for future medical care in older people if they develop advanced dementia, and the stability of those preferences after six weeks.

Design Randomised controlled trial conducted between 1 September 2007 and 30 May 2008.

Setting Four primary care clinics (two geriatric and two adult medicine) affiliated with three academic medical centres in Boston.

Participants Convenience sample of 200 older people (≥65 years) living in the community with previously scheduled appointments at one of the clinics. Mean age was 75 and 58% were women.

Intervention Verbal narrative alone (n=106) or with a video decision support tool (n=94).

Main outcome measures Preferred goal of care: life prolonging care (cardiopulmonary resuscitation, mechanical ventilation), limited care (admission to hospital, antibiotics, but not cardiopulmonary resuscitation), or comfort care (treatment only to relieve symptoms). Preferences after six weeks. The principal category for analysis was the difference in proportions of participants in each group who preferred comfort care.

Results Among participants receiving the verbal narrative alone, 68 (64%) chose comfort care, 20 (19%) chose limited care, 15 (14%) chose life prolonging care, and three (3%) were uncertain. In the video group, 81 (86%) chose comfort care, eight (9%) chose limited care, four (4%) chose life prolonging care, and one (1%) was uncertain (χ2=13.0, df=3, P=0.003). Among all participants the factors associated with a greater likelihood of opting for comfort care were being a college graduate or higher, good or better health status, greater health literacy, white race, and randomisation to the video arm. In multivariable analysis, participants in the video group were more likely to prefer comfort care than those in the verbal group (adjusted odds ratio 3.9, 95% confidence interval 1.8 to 8.6). Participants were re-interviewed after six weeks. Among the 94/106 (89%) participants re-interviewed in the verbal group, 27 (29%) changed their preferences (κ=0.35). Among the 84/94 (89%) participants re-interviewed in the video group, five (6%) changed their preferences (κ=0.79) (P<0.001 for difference).

Conclusion Older people who view a video depiction of a patient with advanced dementia after hearing a verbal description of the condition are more likely to opt for comfort as their goal of care compared with those who solely listen to a verbal description. They also have more stable preferences over time.

Trial registration NCT00704886.


  • We thank the patient and her family, who agreed to be filmed for the purposes of educating and improving decision making at the end of life for all patients. We also thank Claus Hamann, Katherine Hesse, Juergen Bludau, Laurel Yates, Peggy Edson, Ruth Kandel, and Aretha Delight Davis for their contribution to the project.

  • Contributors: AEV, MKP-O, MJB, MRG, EFC, EDA, and SLM were responsible for study concept and design. AEV and AE-J acquired the data, which was analysed and interpreted by AEV, MKP-O, YC, and SLM. AEV, MKP-O, MJB, MRG, EDA, and SLM drafted the manuscript. AEV, MKP-O, MJB, MRG, KLM, EFC, EDA, AE-J, and SLM supervised the study and critically revised the manuscript for important intellectual content. YC did the statistical analysis. AEV, MJB, MRG, and SLM obtained funding. AEV, MKP-O, MJB, KLM, EFC, EDA, AE-J, and SLM were responsible for administrative, technical, and material support. AEV is guarantor.

  • Funding: AEV was supported by a George Bennett Fellowship from the Foundation for Informed Medical Decision Making, a New Investigator Research Grant from the Alzheimer’s Association, and a Center for Excellence Career Development Award from the Hartford Foundation.

  • Role of the sponsor: None of the foundations participated in the collection, analysis, or interpretation of the data or in preparation, review, or approval of the manuscript.

  • Competing interests: None declared.

  • Ethical approval: The protocol was approved by the institutional review board of each participating institution and all participants provided informed consent

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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